Republican health-care policy almost always comes back to cost control. Former House speaker Paul Ryan (R-Wis.) rose to fame in part for his proposal to turn Medicare into a “premium support” program. In simple terms, that meant the federal government would no longer ensure that seniors received care when they need it; rather, it would ensure the payment of a certain amount of money that each senior would use to purchase an insurance plan that, in theory, would provide the same or a better level of care.
The “in theory” part gets to the heart of the GOP’s challenge on health care. Medicare is a good deal for Americans. Seniors largely don’t have to worry about being able to afford the health care they need, especially if they purchase a private supplemental policy. Republican theory holds that the free market would produce a leaner health-care system and that the availability of private insurance policies would provide what Medicare currently does at a lower cost. But we won’t know that would happen unless we make the leap into the unknown, and Americans are typically unwilling to give up a sure thing.
Ryan’s plan, and others modeled on it, was primarily lauded on the right because it solved the “entitlement crisis.” That crisis is real, but it is solely one of cost. Over time, growing health costs and an aging population are projected to drive up government expenditures dramatically. Paying for those added costs would require significant tax hikes, bringing U.S. tax levels much closer to those found in Canada or Britain. Preventing that rise is surely a good thing, but Americans have yet to be persuaded to care more about this than they do about the security of Medicare.
Other federally financed health-insurance programs have similar political dynamics. People are dependent on Medicaid, the Children’s Health Insurance Program and the Obamacare exchanges for their health-care needs. Any cost-saving changes to these programs will make people wonder how it will impact what they value most: their health. Republican efforts to reform these programs always flounder on this legitimate concern.
This is of particular concern for Republicans because of the party’s decades-long image as the party of big business and the rich. This is surely exaggerated, especially today as the well-to-do increasingly become a solid Democratic voting bloc. But the image remains nonetheless. Too many people think the GOP cares more about the money of their donors than the lives of their voters.
Making Republicans the party of health care means reversing this image. It means putting the commitment to health care and financial security first and the goal of cost control second. Given the party’s decade-long inability to come up with an Obamacare replacement plan that does that, the president should be prepared to push his administration to develop and present such proposals on its own.
They have some Republican models they can look at for guidance. President George W. Bush’s Medicare prescription drug program was attacked on the right for costing too much when it was first proposed, but the president stood firm. He intended to guarantee the drug benefit first and worry about costs second. And in fact, Medicare Part D came in well under budget and arguably saved even more money elsewhere in the budget as increasing use of cheaper drugs forestalled use of more expensive hospital stays and other interventions.
A Trump-drafted Republican health-care reform bill would follow similar principles. It would have to accept the risk that the theory could be wrong, that costs could explode once coverage and benefits are guaranteed. But designing a plan so that the risk of failure falls on the federal budget rather than the patient is the right way to go.
Examples abound for what a care-oriented approach could look like. The administration’s efforts to lower drug prices would make effective medicines more readily available. Tackling the quasi-monopoly position many hospitals hold would do something similar for a wide variety of health-care services. Replacing Obamacare’s exchanges with a voucher system coupled with competitive bidding and extensive subsidies for people with preexisting conditions, similar to the model available to federal employees, would guarantee coverage to people currently receiving it while also unlocking market forces to potentially save costs. Allowing large voluntary entities such as churches to offer health insurance to their members on the same terms as employers could also extend unsubsidized coverage to people without jobs that offer health insurance. Each of these ideas focuses more on providing care than on worrying about costs.
Trump broke from Ryan-esque orthodoxy in his campaign by pledging not to tamper with Medicare or Social Security. Doing that was essential to his appeal to the blue-collar Democrats whose support allowed him to break the Democrats’ Midwestern blue wall. They rely on those programs and have long suspected Republicans cared more about profits than people.
As he tries to bring his party along with his vision, Trump needs to remember this: care first, cost second. This is the only way for Republicans to begin to own health care and end their eight-decade image as the Scrooge McDucks of American politics.